You had the foresight to purchase long-term disability insurance benefits to replace your lost income should you become disabled. You’ve consistently paid your disability insurance premiums month after month. Now, you cannot work due to a disabling illness or injury, and the last thing you ever imagined is that the insurance company you’ve been paying would refuse to hold up their end of the bargain.
Unfortunately, it is not uncommon for Unum Group and other big insurance companies to deny legitimate disability claims. If your claim has been wrongfully denied or terminated, we can help. At Ortiz Law Firm, we are dedicated to assisting people in recovering the disability benefits they deserve. We offer a free case evaluation, including a review of your insurance policy and claim determination.
Call our office at (888) 321-8131 to schedule your free case review with a Unum disability lawyer.
Top Reasons Why Unum Denies Long-Term Disability Claims
You Did Not Satisfy Your Elimination Period
HOW LONG MUST YOU BE DISABLED BEFORE YOU ARE ELIGIBLE TO RECEIVE BENEFITS?
You must be continuously disabled through your elimination period. Unum will treat your disability as continuous if your disability stops for 30 days or less during the elimination period. The days that you are not disabled will not count toward your elimination period.
Your elimination period is the later of:
– 180 days; or
– the date your insured Short Term Disability payments end, if applicable.
You are not required to have a 20% or more loss in your indexed monthly earnings
due to the same injury or sickness to be considered disabled during the elimination
You are not required to have a 20% or more loss in your indexed monthly earnings due to the same injury or sickness to be considered disabled during the elimination period.
You Did Not Submit Sufficient Medical Evidence
Insurers often deny claims because there is insufficient evidence to support the claim. For example, if there is an X-ray involving back pain, perhaps better evidence would be an MRI or a CT scan. In a mental illness claim, if there are cognitive deficits or difficulty thinking and processing information, neuropsychological testing may be good evidence. This is the type of evidence an insurance company seeks to evaluate a case.
Unum Conducted a Peer-Review Evaluation
Your denial letter might say, “To give your file every consideration, two physicians reviewed the medical documentation in your claim. The review does not find that you have been precluded from your occupational demands on a full-time basis.”
This means Unum sent your medical records to one of their doctors, and their doctor has given an opinion as to what you can and can’t do, even though that doctor has never seen or examined you.
Unum Ordered a Vocational Analysis of Your Claim
A vocational analysis means that the disability insurance company sent your file to a job expert who reviewed it and determined that you can return to work in some capacity. Your denial letter may state, “We had your file reviewed by our Vocational Specialist to assess the occupation duties of your own occupation.”
You Do Not Meet the “Any Occupation” Definition of Disability
Most long-term disability policies have a definition of disability that changes from “own occupation” to “any occupation” after a certain number of months. This typically occurs after benefits have been payable for 24 months. The differences between the two can be technical and confusing, and the insurance company will do whatever it can to muddy the waters and make your long-term disability claim harder to avoid payouts. The excerpt below is an example from a real policy:
HOW DOES UNUM DEFINE DISABILITY?
You are disabled when Unum determines that:
– you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and
– you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.
After 24 months of payments, you are disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.
You must be under the regular care of a physician in order to be considered disabled.
The loss of a professional or occupational license or certification does not, in itself, constitute disability.
We may require you to be examined by a physician, other medical practitioner and/or vocational expert of our choice. Unum will pay for this examination. We can require an examination as often as it is reasonable to do so. We may also require you to be interviewed by an authorized Unum Representative.
Mental Health Claims Have a Limited Benefits Period
Most disability insurance companies will only pay claims due to mental illness for a limited time (typically 12-24 months), but your benefits should continue if you also have physical conditions that prevent you from working. Unum will try to say your physical conditions are not disabling so it can justify the claim denial.
WHAT DISABILITIES HAVE A LIMITED PAY PERIOD UNDER YOUR PLAN?
The lifetime cumulative maximum benefit period for all disabilities due to mental
illness is 12 months. Only 12 months of benefits will be paid even if the disabilities:
– are not continuous; and/or
– are not related.
Unum will continue to send you payments beyond the 12 month period if you meet one or both of these conditions:
1. If you are confined to a hospital or institution at the end of the 12 month period, Unum will continue to send you payments during your confinement. If you are still disabled when you are discharged, Unum will send you payments for a recovery period of up to 90 days. If you become reconfined at any time during the recovery period and remain confined for at least 14 days in a row, Unum will send payments during that additional confinement and for one additional recovery period up to 90 more
2. In addition to Item 1, if, after the 12 month period for which you have received payments, you continue to be disabled and subsequently become confined to a hospital or institution for at least 14 days in a row, Unum will send payments during the length of the reconfinement. Unum will not pay beyond the limited pay period as indicated above, or the maximum period of payment, whichever occurs first.
Unum will not apply the mental illness limitation to dementia if it is a result of:
– viral infection;
– Alzheimer’s disease; or
– other conditions not listed which are not usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs, or other similar methods of treatment.
The policy excerpts above are sourced from a real Unum group long-term disability insurance policy. If Unum has denied your long-term disability insurance claim, regardless of the specific reason for the denial, it is strongly recommended that you do not proceed through the appeal process without first requesting a free case evaluation by an experienced disability lawyer.
What Language Does Unum Use in Denying a Claim?
In deciding upon an appeal to a denial, Unum may respond: “We determined the decision on the claim is correct.”
They may hire a vocational expert/consultant: “On appeal, we had our vocational rehabilitation consultant (VRC) review the demands of your client’s regular occupation as it is performed in the national economy based on the concerns you brought up on appeal.”
Unum may have the file go under a “Medical Review”: “On appeal, [your client]’s claim was reviewed by a clinical consultant and a physician board certified in PM&R (physical medicine and rehabilitation).”
Unum will likely conclude: “Based on our review, the decision to deny benefits is appropriate. The available file information supports she has the functional capacity to perform her regular occupation.”
Is Unum Hard to Deal With?
Do I Have a Unum Disability Insurance Policy?
How Do You Fight Unum Disability Insurance Claim Denials?
Receiving a Unum disability denial does not mean that all hope is lost. If your Unum disability claim is denied or terminated, you have the right to file an appeal. Many claimants choose to retain a disability law firm to assist them in fighting their claim denials, and most disability lawyers offer a free legal consultation.
However, you are not required to hire an attorney to represent you, even if you take advantage of a free consultation. If you are interested in appealing on your own, we recommend that you review our free disability insurance appeal guide first. It will help you to understand the steps disability insurance lawyers follow when preparing an appeal.
If you prefer to work with a disability expert, we hope you will consider our law firm. With over a decade of experience handling Unum disability claims nationwide, Nick Ortiz has the insight and skills to help you recover the long-term disability benefits you deserve.
How Can A Disability Insurance Lawyer Help?
Our goal is to document your disability in a manner that demonstrates your impairments and that you cannot work. We will work with you to gather the appropriate evidence and documentation to satisfy the requirements of your disability policy. We will also prepare Attending Physician Statements customized to your medical conditions.
Unum may provide you with a generic Attending Physician’s Statement form, but this form will not be customized for your situation. Forms from the insurer are designed to apply to any claim, whether the claimant is suffering from a heart condition or a broken ankle. Using a customized form that only asks about the limitations and restrictions that apply to you will make it much easier for your doctor to complete the form.
Can I Sue Unum Over a Disability Denial?
In some cases, we are successful in having Unum put the claimant “on claim,” which means that the claim was approved and benefits were paid during the internal appeals process with Unum’s claims handling department without resorting to a lawsuit against the insurance carrier. In other instances, however, Unum may uphold the decision to deny or terminate your claim. If so, you may be able to sue Unum over the disability denial.
Do I Have to File an Appeal Before I Can File a Lawsuit Against Unum Group?
Whether you have to file an appeal before filing a lawsuit depends on how you obtained your Unum disability insurance policy. Unum is an insurance company offering both group and individual disability insurance policies. Your legal rights with a group policy differ greatly from those with an individual policy.
If your policy is part of a group benefits plan through a private employer, employee organization, or union, then it is likely governed by ERISA, and you will have to file at least one appeal before suing the insurance company. Should the internal appeals process fail, you have the right to file an ERISA lawsuit to have your case reviewed by a federal judge. Under ERISA, the disability insurance company has no exposure to bad faith damages and thus has no real incentive to pay the claim.
It is almost always better to have an individual policy. If you have an individual policy, or if a church or a government employer provides your policy, then your claim is likely not governed by ERISA, and you may not have to file any appeals before filing a lawsuit. Bad faith damages also come into play, as bad faith laws apply only if ERISA regulations do not apply. If your Unum claim was denied and you’ve exhausted your appeals, or if you’re trying to determine if you have to file an appeal, our Unum insurance lawyers are here to help.
Get Help from an Experienced Unum Disability Lawyer
Mr. Ortiz has helped hundreds of disability insurance claimants recover the disability benefits they deserve. We understand how frustrating it can be to go through the Unum claims handling process to receive a disability claim denial, and we will gladly help you through the process. The experience we have gained while helping past clients fight insurance companies such as Unum has given us great insight into the best steps to improve your chances of winning your claim.
Request a free case evaluation if your benefits have been wrongly denied or terminated. This is your opportunity to discuss the specific details of your unique situation, and there is no obligation to retain our firm. We also handle Social Security Disability claims, so if you have a concurrent claim with the Social Security Administration, we can assist you with that claim as well.
If you’d like to learn more about how we can help you fight to prove your inability to work and recover the denied disability benefits you deserve, Call our office at (888) 321-8131 to schedule your free consultation today.